Clinical Quality Nurse Reviewer, Sr. Specialist - Prior Auth​/UM- Remote

Clinical Quality Nurse Reviewer, Sr. Specialist - Prior Auth/UM
- Remote

Date:
Aug 28, 2026

Location:

Any city, TX, US, 99999

Work Mode:
Virtual (Exception only)

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards.

You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

We are seeking a talented individual for a Clinical Quality Nurse Reviewer, Sr. Specialist who is responsible for performing ongoing quality assurance audits, clinical claims reviews, and clinical/coding audits of medical records and related documentation. This position evaluates whether review determinations align with medical records, approved clinical and coding guidelines, regulatory requirements, and contract-specific review methodologies. Responsibilities include reviewing documentation to ensure all aspects of the review audit have been addressed properly and accurately.

Participating in inter-rater reliability assessments and quality assurance auditors for multiple review types including Place of Service, Level of Care, Readmissions, Utilization Management and other specialty reviews.

This position requires strong clinical expertise, advanced auditing experience, and experience applying clinical guidelines such as Inter Qual and MCG to support accurate quality review outcomes and contribute to continuous improvement across clinical review solutions.

• Perform Quality Assurance audits using approved clinical guidelines and policies, and document determinations clearly and concisely.
• Analyze and review production and appeal documentation to ensure all aspects of the review are addressed properly, accurately, and in accordance with regulatory requirements while meeting production goals and quality standards.
• Provide detailed documentation of quality review results for trending and reporting. Identify quality trends and work with leadership to develop remediation activities, including educational materials and training sessions to improve the quality of clinical solutions.
• Assist management with training new reviewers, including daily monitoring, mentoring, feedback, and education. Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure.
• Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
• Actively cross-train to perform reviews of multiple claim types and support a flexible workforce that meets client needs.
• Serve as a subject matter expert and contribute to the business proposal process.
• Assist with projects, data analysis, reporting, and feedback as directed by department leadership.
• Demonstrate experience in medical review, chart audits, and quality improvement processes.
• Analyze and evaluate medical information and apply clinical review guidelines and judgment to make clinical determinations.

• Active, unrestricted RN license in the United States and the state of primary residence.
• An active, unrestricted multistate compact RN license as defined by the Nurse Licensure Compact (NLC) is required. Associate degree required; bachelor's degree preferred.
• 5+ years of clinical experience in an acute care setting.
• 5+ years of medical record review/auditing, utilization management, or appeals/hearing experience preferred.
• 3+ years of experience applying national evidence-based guidelines (Inter Qual and/or MCG).
• Expert-level experience applying MCG and/or Inter Qual criteria; MCG or Inter Qual certification preferred.
• Excellent written communication skills, including the ability to write clear, concise, accurate, and fact-based rationales to support determinations.
• Ability to multitask in a fast-paced production…